Lessons Learned During the Pandemic

with Dr. Manisha Kulshreshtha and Dr. Dan Lombardi

March 2020 was when New Yorkers were first introduced to a lethal virus that would soon change the lives of frontline workers and patients in hospital emergency rooms and ICU’s throughout the city. Within weeks, the United States became the country hardest hit by the pandemic and New York City was recording its one thousandth death.

The Bronx was among those areas most cruelly targeted by COVID-19. As devastating as the losses were and continue to be, generals on the front lines like Dr. Manisha Kulshreshtha, Senior Vice President – Medical Director; and Dr. Dan Lombardi, Senior Vice President, Chief Academic & Quality Officer at SBH Health System, managed to stitch a plan together that in the ensuing months would save the lives of countless others.

Here is an excerpt from a recent interview with Drs. Kulshreshtha (MK) and Lombardi (DL) on the podcast SBH Bronx Health Talk about this difficult time.

Is it fair to say that when COVID-19 first hit the Bronx, hospitals in general were not prepared to fight it?

(MK) I think that’s very fair to say. We did not expect it to happen so quickly. It hit us so fast and so hard. I think we thought we would have more time to prepare, but unfortunately we didn’t and we had to use everything at our disposal to get to where we were and we did the best we could.

We did a fantastic job. Everyone pitched in. We met. We planned. Seven days a week to make sure we could get to where we could. It started off as soon as we first heard about Covid in Wuhan, China. We knew that at some point it would come to the U.S. When that happened, and I think we started hearing about in February, we started getting ready. We had a plan in place on what we would like to do to expand our bed capacity. What we would do to take care of our patients. We started early and we shut down a lot of things early so we would be able to prepare for the influx of patients.

Do you think the reality of the virus when it first hit exceeded your expectations?

(MK) Absolutely. I did not expect it to be so hard so fast. In the beginning, if you remember, what we heard on the news was that it was similar to the flu. It had perhaps a one percent mortality rate or even less, only it did not turn out that way. We did not know what to expect when it came to the clinicals of what a patient would be experiencing when they came in. We did not know it would be that kind of disease where we would be sending patients home from the emergency room and they would return. We did not expect them to come in and die so quickly. It was almost like an avalanche of patients coming in very very quickly. We did not expect that and had to gear up for that. We had a plan with phases a, b, c, d and we thought we’d go in steps. I think very quickly within a day or two we went from phase a to phase d.

Is it fair to say that St. Barnabas and other hospitals went down some dead ends in trying to find solutions?

(DL) Yes, I do think it’s fair to say we found some dead ends and I think some of that had to do with staffing, some of that had to do with equipment and supplies. You know, like Manisha said, at some point we were scrambling. We were scrambling to get help from staffing models. We were trying to get help from our partners and we did receive a lot of help. We received help from Greater New York Hospital Association (GNYHA). We received help from the Healthcare Association of New York State (HANYS). We received help from the community. So many donations of PPE, other supplies and food and support for our staff. I mean while it was tragic and still remains tragic it really was great to see how people came to help people at a great time of need.

Did you find that that certain drugs weren’t as effective as they were hyped up to be?

(DL) Yes, what came with this virus was a lot of uncertainty. There was a lot of publicity surrounding certain drugs that were touted to work really well and we tried them and we tried our best to manage with all that uncertainty. Some have proven to work. We still are now treating patients with some of the drugs that we used a year ago and others have fallen by the wayside.

What protocols were put in place that you found were effective over the course of the pandemic and continue to be?

(MK) I think isolation of course was very very important. Masking, very important. I know the guidelines kept changing, it felt like by the day. Sometimes policies would change immediately as soon as they came out and we had to make sure we were doing the right thing. I think isolation, masking – making sure that everyone wore a mask at all times that has continued to this day. We started this very early, well before the CDC even recommended it. As Dan mentioned some therapies that we had started, namely things like steroids, we continue right now, maybe different types, maybe different doses, as we’ve refined what has come out in the literature. We have continued oxygen therapies. We have many different modalities that we continue to provide to our patients. We had anticoagulation in the beginning that we were not sure would work, but I think we have our protocols in place right now and early on I believe Remdesivir came on. I remember Dr. Berger [Dr. Judith Berger, director of infectious diseases] putting so much time and effort writing letters to the company explaining that we were a small hospital, that we are in the middle of the Bronx, which is probably one of the hardest hit areas in New York, in the world, and we needed to have this for our patients. They responded and they gave us some of the drug. It was actually a very good thing that we got it early and we’ve continued to use that therapy to this day. At a time when it was so early no one really knew what the right therapy was, it was all trial and error, and there was some anecdotal evidence of what could work, what did not work. I think one, two, three, four years from now when we’re still dealing with Covid we’ll find out more and we’ll see what was right, what was wrong, but I think at the time we did the best we could. We used the therapies that were available to us. We used the best guidance we had. We used what evidence-based guidance we had and as soon as some things changed or once there was more evidence we would start using those therapies as well. So I think Dr. Telzak [Dr. Edward Telzak, chair, Department of Medicine] led that very very well, along with Dr. Berger and many others in the committee. I think where we are today is in a good place. I think we’re seeing better outcomes, still tragic as every single death is, but I think where we were then and where we are now is a different place, but we need to keep getting better at this.

Where do we stand with ventilators? I mean from what we’ve read those patients who were put on ventilators didn’t have great outcomes. Are we moving on from ventilators?

(MK) I think ventilators still have a place in therapy. When someone requires that level of oxygen we still use ventilators. We were using ventilators obviously much more frequently, but I think it was also because of the level of illness and the number of individuals coming in. We now find that high flow oxygen actually works quite well. We also are treating earlier, we’re able to identify patients much earlier, so we can treat it when the symptoms are not as bad as they were when they were coming in. I think we are much better at that now, so yes there still is a place for ventilators but there is also a place for other oxygen modalities that we’ve used. We have tents, we have cpap, we have bipap, we have high flow oxygen, so we try to use all of those before we move on to ventilators and I think that’s something that we’ve learned over the year.

I know when then President Trump tested positive and was treated at Walter Reed Hospital the media was saying, well, this is not the kind of treatment available for the average patient. But from what I understand what’s being done at St Barnabas Hospital is really not that different, right?

(DL) Yes, I would agree with that statement. I mean, and Manisha already kind of outlined, some of the modalities in treatment that are available at SBH and those are the same modalities and treatments that are available elsewhere. You know Remdesivir and steroids now are a mainstay of treatment. For those patients that need more oxygen we have cpap and bipap and high flow oxygen using demystifiers – those are the tents that she’s describing – or bipap helmets that we’ve been trialing and even those patients that unfortunately have to get intubated and put on a ventilator we’re using certain techniques that are used across the world. We’re proning those patients, trying to oxygenate them in a better capacity. We’re also using monoclonal antibodies. We’re using the latest modalities, treatments and drugs.

Are there still things about COVID-19that keep you up at night, that still concern you?

(MK) Absolutely. I think this is a disease that’s just testing us. I have to say when it first came out we were not aware of the variants that are now out there. We thought there was one covariate, we’ll treat it hopefully, and one day soon we’ll get a vaccine. I did not expect a vaccine to come so quickly and I’m just so impressed with the world and how everyone came together to get so many different kinds of vaccines. It’s just incredible to me how quickly that occurred, but yes, it was a matter of time before I think any virus can mutate and modify and we have some variants that because of travel we will get from different parts of the world. We do have one from Washington Heights now that is, I think pretty much in the Bronx, that’s keeping me up at night as well. You wonder how much of this would be amenable to treatment, whether we’re going to get another surge. Masking is still very, very important. Summer is going to come, we’re going to be out.

Are we going to be wearing our masks? Are we going to be doing the right thing? It does keep me up at night because you worry about our patients. You worry about exposures. You worry about our healthcare workers. You worry about the community bringing it into us. It’s a never-ending cycle because you just need that one case to go out of control to get another surge within the hospital and that’s something we definitely do not want. So yes, the variants keep me up at night, vaccinations keep me up at night. I would like to see us get 100 percent vaccinated, as quickly as possible. I want everyone safe. I don’t want there to be a single death from Covid, but you know the reality is we all need to do what we can and I think we all need to understand that this is not going to go away. We all want to get back to our lives, but I think it could go either way and we need to be very, very aware of that. When we hear about certain states that are now fully opening up what do you think about that? Is it premature?

(DL) Definitely seems premature. You know it’s a difficult thing to kind of
bring up and discuss and I understand the fatigue. I understand the anxiety and the depression. It seems like we should be further along. We’re opening up our states and the economy to allow no mandates as far as masks are concerned and all the isolation and the social distancing that’s required. There’s just so much that’s still unknown and until we learn more this seems a bit premature.

Some of these so-called experts and some of the scientists out there say that by 2022 we should be back to normal. What do you think about that?

(MK) It’s a very good question. I wish I could look into the future in a crystal ball and say that would occur. I don’t know what a new reality is going to be. I think we’re seeing ebbs and flows. It surges up, it comes back down and sometimes we don’t even know why. I think vaccination is going to play a huge part. I do not know whether we need to vaccinate once a year, once every nine months, once every five years. We don’t know what that’s going to be like. We don’t know how well we’re going to be able to vaccinate the world. I’m hoping that in 2022 we’ll be in a much better place. I’m hoping it be close to normal, but I think we have to see. I think we have to do the right thing right now before we say “Okay, we’ll just look forward to 2022, it’s going to be okay.” We have to do the work. We have to do the right thing from now until then and see where we are then. We are not one small isolated country. This is the entire world we’re talking about because we all travel, we all go to different areas and we can bring back something that we might not want to bring back. So, we have to continue to be careful, continue to nip this. But I hope that one day this will be just like the flu. Yes, the flu is also deadly, but it’s not like Covid. If it does come to that we have to live with Covid for the rest of our lives, it needs to be something that we can control and is something that is not as serious and fatal as it is right now.